Provider Demographics
NPI:1497851562
Name:GOODALE, DIANNE L (MD)
Entity Type:Individual
Prefix:
First Name:DIANNE
Middle Name:L
Last Name:GOODALE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 CLINIC DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1661
Practice Address - Country:US
Practice Address - Phone:270-825-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY32926208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY32926OtherLICENSE
000000044287OtherBCBS PROVIDER NUMBER
KY64329261Medicaid
G40886Medicare UPIN
KY010058274Medicare PIN
KY32926OtherLICENSE
KY64329261Medicaid